- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,548.82 / $3,981.07
| Facility | | $1,513.56 | $1,548.82 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.88 / $131.83 / $234.42
| Professional | | $58.88 | $131.83 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.88 / $134.90 / $245.47
| Professional | | $58.88 | $134.90 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $128.82 / $281.84
| Professional | | $79.43 | $128.82 | $281.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,454.71 / $6,025.60
| Facility | | $1,380.38 | $2,454.71 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $63.10 / $128.82 / $257.04
| Professional | | $63.10 | $128.82 | $257.04 |